食管切除术后胸腔内吻合口漏的外科处理和防治

目的探讨食管切除术后胸内吻合口漏的原因、治疗及预防。方法 1 812例食管切除术患者55例术后发生胸内吻合口漏,其中28例行非手术治疗,27例行手术治疗。结果非手术治疗的28例吻合口漏中,22例治愈,4例死亡,2例放弃治疗;手术治疗的27例中,26例治愈,死亡1例为吻合口漏修补术后再次发生吻合口漏,多脏器功能衰竭死亡。结论食管切除术后胸内吻合口漏病情危重,死亡率高,术中及围手术期采取有效预防措施可降低吻合口漏的发生率。治疗应首先采用非手术方法,如无好转应尽早手术治疗。治疗目的在于通畅引流,辅以肠内营养可取得较好治疗效果。     

直肠癌全系膜切除术后吻合口瘘原因分析及防治措施

目的：分析直肠癌全直肠系膜切除术后发生吻合口瘘的原因及防治措施.方法：回顾性分析自2003年1月至2007年12月在我院行全直肠系膜切除保肛手术的214例中低位直肠癌患者的临床资料.结果：214例患者术后共发生吻合口瘘16例（7.5％）.发生时间为术后4-15d,平均（6.8±1.4）d.其中性别、肿瘤Dukes分期、病理类型及有无结肠储袋等对术后吻合口瘘的发生率没有显著影响,差异无统计学意义（P＞0.05）.而年龄、术前有无贫血及低蛋白血症、糖尿病史、有无合并肠梗阻、手术方式、吻合器应用、吻合器吻合后手工缝合减张及术后直肠留置肛管引流减压对术后吻合口瘘的发生率均有明显影响（P＜0.05）.4例严重吻合口瘘的患者并发弥漫性腹膜炎行横结肠造瘘术,术后4个月成功闭瘘.12例较轻的吻合口瘘患者采用单纯完全静脉营养、抗生素治疗、经引流管局部冲洗等措施全部治愈,愈合时间为14d至3个月,平均（28.7±2.3）d.术后无死亡患者.结论：高龄、贫血、低蛋白血症、合并糖尿病及肠梗阻、低位吻合口等是术后发生吻合口瘘的高危因素.吻合器吻合后手工缝合加固减张,术后直肠内留置肛管减压引流可显著减少吻合口瘘的发生.积极合理的采取非手术或手术措施治疗吻合口瘘是促进吻合口愈合的关键.     

Effectiveness of a Transanal Drainage Tube for the Prevention of Anastomotic Leakage after Laparoscopic Low Anterior Resection for Rectal Cancer

Background and Objective: Anastomotic leakage is one of the most serious complications after laparoscopic low anterior resection Low Anterior Resection (LAR) for rectal cancers. The purpose of this study was to evaluate the effectiveness of a transanal drainage tube placed for the prevention of anastomotic leakage after laparoscopic LAR. Methods: The clinical data of 220 patients with rectal cancer who underwent laparoscopic LAR using the double stapling technique Double Stapling Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Technique (DST) from Jun 2017 to Dec 2018 were analyzed retrospectively at our institution. A transanal drainage tube was placed after anastomosis in 120 patients (TDT group). Another 100 patients were operated on without a transanal drainage tube (NTDT group). Clinicopathological and surgical factors, the frequencies of anastomotic leakage and re-operation after leakage were compared between the two groups. Results: Patient age, gender, body mass index, American Society of Anesthesiologists (ASA) score, previous abdominal surgery, intraoperative blood loss, tumor size, tumor stage, specimen length, distance of tumor from the anal verge, and operative time were comparable between the two groups. Overall rate of leakage was 4.5% (10/220). The frequency of leakage was 3.3% (4/120) in TDT group and was 6.0% (6/100) in NTDT group. The rate of leakage was significantly lower in TDT group (p<0.05). Furthermore, the re-operation rate for symptomatic anastomotic leakage was 50.0% (2/4) in TDT group, while in contrast it was 83.3% (5/6) in NTDT group. The rate of re-operation was lower in TDT group than NTDT group (p<0.05). Conclusions: The use of a transanal drainage tube in laparoscopic LAR for rectal cancer is a simple and effective method for prevention of anastomotic leakage and decreases the rate of re-operation after symptomatic leakage.     

Anastomotic leakage in colorectal cancer surgery

The safety of colorectal surgery for oncological disease is steadily improving, but anastomotic leakage is still the most feared and devastating complication from both a surgical and oncological point of view. Anastomotic leakage affects the outcome of the surgery, increases the times and costs of hospitalization, and worsens the prognosis in terms of short- and long-term outcomes. Anastomotic leakage has a wide range of clinical features ranging from radiological only finding to peritonitis and sepsis with multi-organ failure. C-reactive protein and procalcitonin have been identified as early predictors of anastomotic leakage starting from postoperative day 2–3, but abdominal-pelvic computed tomography scan is still the gold standard for the diagnosis. Several treatments can be adopted for anastomotic leakage. However, there is not a universally accepted flowchart for the management, which should be individualized based on patient's general condition, anastomotic defect size and location, indication for primary resection and presence of the proximal stoma. Non‐operative management is usually preferred in patients who underwent proximal faecal diversion at the initial operation. Laparoscopy can be attempted after minimal invasive surgery and can reduce surgical stress in patients allowing a definitive treatment. Reoperation for sepsis control is rarely necessary in those patients who already have a diverting stoma at the time of the leak, especially in extraperitoneal anastomoses. In patients without a stoma who do not require abdominal reoperation for a contained pelvic leak, there are several treatment options, including laparoscopic diverting ileostomy combined with trans-anal anastomotic tube drainage, percutaneous drainage or recently developed endoscopic procedures, such as stent or clip placement or endoluminal vacuum‐assisted therapy. We describe the current approaches to treat this complication, as well as the clinical tests necessary to diagnose and provide an effective therapy.     

Recent improvements in the management of esophageal anastomotic leak after surgery for cancer

Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage.Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures.Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed.Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.     

Arterial calcification is a risk factor for anastomotic leakage after esophagectomy: A systematic review and meta-analysis

BackgroundLeakage of the esophago-gastrostomy after esophagectomy with gastric tube reconstruction is a serious complication. Anastomotic leakage occurs in up to 20% of patients and a compromised perfusion of the gastric tube is thought to play an important role. This meta-analysis aimed to investigate whether arterial calcification is a risk factor for anastomotic leakage in esophageal surgery.MethodEmbase, Medline, PubMed, Cochrane databases and Google scholar databases were systematically searched for studies that assessed arterial calcification of the thoracic aorta, celiac axis including its branches, or the superior mesenteric artery in patients that underwent esophagectomy with gastric tube reconstruction. The degree of calcification was classified as absent, minor or major. A “random-effects model” was used to calculate pooled Odds Ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the Q-test and I²-test.ResultsFrom the 456 articles retrieved, seven studies were selected including 1.860 patients. The median (range) of anastomotic leakage was 17.2% (12.7–24.8). Meta-analysis showed a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18(CI 1.42–3.34)), celiac axis (OR 1.62(CI 1.15–2.29)) and right post-celiac axis (common hepatic, gastroduodenal and right gastroepiploic arteries) (OR 2.69(CI 1.27–5.72)). Heterogeneity was observed for analysis on calcification of the thoracic aorta and celiac axis (I² = 71% and 59%, respectively) but not for the right branches of the celiac axis (I² = 0%).ConclusionThis meta-analysis, including good quality studies, showed a statistically significant association between arterial calcification and anastomotic leakage in patients who underwent esophagectomy with gastric tube reconstruction.     

食管癌术后颈部吻合口后壁瘘的临床分析

目的 探讨食管癌术后颈部吻合口后壁瘘的临床特点及治疗对策。 方法 回顾性分析安阳市肿瘤医院胸三科2007年1月至2015年12月食管癌切除术颈部吻合口后壁瘘患者的临床资料。 结果 共1623例患者行食管癌根治术并行颈部器械吻合。其中左颈、左胸两切口1182例,右颈、右胸及上腹三切口425例,左颈、上腹两切口（食管拔脱术）16例。发生吻合口瘘共82例（5.1%,82/1623）,其中后壁瘘15例（0.9%,15/1623）。瘘入纵隔者2例,瘘入胸腔者2例,局限于颈部者11例。均采用保守方法治疗。最终治愈14例,1例未愈。 结论 后壁瘘发生的原因主要是吻合器型号选择过大或吻合口张力过大。治疗应个体化。有效引流为重中之重。     

管状吻合器在食管癌颈部吻合中的改进及应用体会

背景与目的：食管癌颈部吻合与胸内吻合相比能减少术后并发症,但吻合151瘘和吻合口狭窄仍是食管癌颈部吻合的主要并发症,而吻合器则能有效减少此术后并发症。本研究改进了管状吻合器在食管癌颈部吻合的操作步骤并评价其临床疗效。方法：对2006年10月至2008年4月127例食管癌患者行食管癌根治术。胃代食管置入食管床,改进了管状吻合器在颈部的操作步骤并进行食管胃器械吻合。分析术后并发症发生情况。结果：全部患者无手术死亡及吻合口出血,吻合口瘘1例（0．8％）,吻合口狭窄5例（3．9％）,经扩张后好转。结论：改进后的管状吻合器颈部吻合技术安全有效,可降低术后吻合口并发症。     

Ultrathin endoscopy versus computed tomography in the detection of anastomotic leak in the early period after esophagectomy

BackgroundAnastomotic leak after esophagectomy is a major postoperative complication that leads to significant mortality. The aim of this study was to evaluate the safety of early postoperative ultrathin endoscopy in detecting anastomotic leaks and compare diagnostic performance of ultrathin endoscopy and computed tomography (CT) scan in identifying anastomotic leak after esophagectomy.Materials and methodsA prospective trial of 71 patients undergoing esophagectomy was conducted between January 2016 to December 2017. A contrast CT was performed prior to ultrathin endoscopy on postoperative day 5–7.ResultsAll 71 patients underwent ultrathin endoscopy and CT scan safely without complications. Among the 71 patients, transoral ultrathin endoscopy was performed on 51 patients and 20 patients with hypertension and coronary artery disease received transnasal ultrathin endoscopy. Overall, 14 leaks (20%) were identified. Endoscopy not only correctly identified the 2 patients of false-positive evaluations by CT, but also determined 4 leaks that were missed on CT. In addition, ultrathin endoscopy accurately identified 3 potential leaks based on pathological findings of anastomosis: ischemia and much fibrin coverings. One patient with normal postoperative CT findings showed healthy anastomosis but an ulcer on gastric conduit on endoscopy. Both sensitivity and specificity of endoscopy were 100%, while sensitivity and specificity of CT were 71.4% and 96.5%.ConclusionsUltrathin endoscopy after esophagectomy is safe and provides more accurate and reliable identification of anastomotic leak than CT scan. Ultrathin transnasal endoscopy may be a more appropriate diagnostic test to detect anastomosis for patients with hypertension and coronary artery disease.     

Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma.

AIMS: The management of anastomotic leakage of the oesophago-jejunostomy after total gastrectomy for gastric carcinoma was evaluated in a retrospective study. PATIENTS AND METHODS: Over a 30-year period, a total of 1114 oesophago-jejunostomies were performed during total gastrectomy for gastric cancer. In 83 cases (7.5%) a leak of the oesophago-jejunostomy was diagnosed. RESULTS: Frequency of anastomotic leakage was independent of the type of reconstruction and of surgical radicality. Therapeutic management was conservative in 58 cases (69.9%), with placement of a naso-jejunal tube along the anastomoses and with percutaneous drainage of intraabdominal abscesses. In 25 patients re-operation with resuturing of the anastomoses or surgical drainage of an abscess was performed. Mortality was 11/58 (19%) after conservative treatment of the anastomotic leakage and 16/25 (64%) after re-operation. CONCLUSION: Conservative management with a naso-intestinal tube and percutaneous drainage of intraabdominal abscesses is realistic for anastomotic leaks. Re-operation results in a high morbidity and should only be considered when conservative management is not successful.     

直肠癌前切除术后吻合口瘘的危险因素及治疗方法分析

[目的]探讨直肠癌前切除术后发生吻合口瘘的高危因素及其处理方法。[方法]回顾性分析自1999年1月至2008年7月1677例行直肠癌前切除术患者的临床资料及发生吻合口瘘后的治疗措施。[结果]共有44例患者（2．6％）术后发生吻合口瘘,其诊断发生吻合口瘘的中位时间为术后第6d。单因素分析显示,男性、肿瘤下缘距肛门小于7cm、术前肠道梗阻为术后吻合口瘘的独立危险因素。出现吻合口瘘后,有9例患者采取了保守治疗,19例患者立刻采取了积极手术治疗,另有16例患者在保守治疗无明显疗效后采取了手术治疗。[结论]男性、肿瘤下缘距肛门小于7cm、术前肠道梗阻的直肠癌前切除术患者易出现吻合口瘘,治疗方式应根据病人临床状况选择。     

低位直肠癌保肛术后吻合口漏的原因及防治

目的探讨低位直肠癌保肛术后吻合口漏的原因、预防及处理方法。方法对低位直肠癌全系膜切除低位吻合手术后吻合口漏的发生及治疗情况进行回顾性分析。对吻合口漏的患者采用保守治疗（经腹部引流冲洗和会阴引流管引流）及手术治疗。结果术后发生吻合口漏18例。采用保守治疗16例,行手术治疗2例,均痊愈出院。结论低位直肠癌保肛术后吻合口漏应以预防为主,满意的术前准备,掌握低位直肠癌保肛术要点并注重操作细节是预防吻合口漏的关键。恰当引流管放置以利于充分引流对吻合口漏的治愈具有重要意义。     

直肠癌术后吻合口出血的病因分析及对策

目的探讨直肠癌术后吻合口出血的常见病因及防治对策。方法对我院2005年1月至2009年12月间共收治的386例直肠癌患者行Dixon术后出现的吻合口出血并发症进行回顾性分析并文献复习。结果 386例直肠癌Dixon术后有6例发生吻合口出血,常见病因包括糖尿病等伴发病和吻合口张力等导致吻合口瘘的因素;吻合时技术因素。结论直肠癌Dixon术后吻合口出血并发症常见病因有糖尿病等伴发病和吻合口张力等导致吻合口瘘的因素;吻合时技术因素。直肠癌Dixon术后吻合口出血以预防为主。     

食管癌腔镜术后营养途径的选择

  目的  探讨食管癌腔镜术后不同营养途径对患者恢复的影响。  方法  回顾性分析2010年5月至2013年10月在郑州大学附属肿瘤医院胸外科行食管癌腔镜手术的310例患者临床资料, 其中术中放置鼻十二指肠管102例, 空肠造瘘98例, 术后早期进食110例。比较3组患者术前, 术后第4天血清白蛋白、体重; 术后第1次排气时间、住院时间; 吻合口瘘、肺部感染及鼻胃减压管拔除后咽喉不适、造瘘口渗液感染等导管相关并发症发生率。  结果  3组均无住院死亡。鼻十二指肠管组与空肠造瘘组术后第1次排气时间、住院时间相比无显著性差异, 而早期进食组较这两组时间明显缩短, 差异有统计学意义。3组患者均未出现术后急性胃扩张及胃排空障碍, 在吻合口瘘和肺部感染发生率方面差异无统计学意义。鼻十二指肠管组在鼻胃减压管拔除后咽喉部不适高于空肠造瘘组, 术后有11%的患者自行拔管。空肠造瘘组术后有5例患者出现造瘘口渗液, 其中有1例较严重者予拔除造瘘管, 有5例患者出现不全肠梗阻。  结论  早期经口进食是食管癌腔镜术后较适宜的营养途径, 符合患者的生理状态, 减少手术带来的应激, 提高患者的依从性, 促进加速康复, 缩短住院时间。      

腹腔镜直肠癌保肛手术后吻合口瘘的危险因素与对策

目的：吻合口瘘为直肠癌保肛手术后严重的并发症之一,增加和患者的痛苦和经济负担。腹腔镜直肠癌根治术已经发展为主流术式,因此研究此术式下吻合口瘘的危险因素显得尤为重要。本研究探讨腹腔镜直肠癌保肛手术后发生吻合口瘘的危险因素及吻合口瘘的防治办法,以期提高腹腔镜直肠癌保肛手术的综合效果,降低吻合口瘘的发生率。方法回顾性分析2010-01-01—2015-06-30北京大学第九临床医学院行腹腔镜直肠癌保肛手术160例患者的临床资料,总结患者性别、年龄、伴有糖尿病、体质量指数、肿瘤最大直径、术前血红蛋白、术前血白蛋白、病理结果、术中出血量、手术时间、离断血管水平、预防性造口、手术方式、肿瘤下极距齿状线距离和新辅助放化疗的情况,统计吻合口瘘的发生情况,并进行单因素和 Logistic 多因素回归分析。分析吻合口瘘的相关危险因素及处理措施和效果。结果吻合口瘘发生率为8．75％（14／160）。单因素分析显示,腹腔镜直肠癌保肛手术后发生吻合口瘘组与未发生瘘组在患者体质量指数（χ2＝4．974,P ＝0．026）、术前白蛋白水平（χ2＝5．749,P ＝0．016）、超低位保肛（χ2＝8．270,P ＝0．004）、手术方式（χ2＝10．27,P ＝0．001）和新辅助放化疗（χ2＝7．540,P ＝0．006）方面,差异有统计学意义。Logistic 多因素回归分析结果显示,体质量指数（OR＝22．156）、吻合口距齿状线距离（OR＝9．742）、手术方式（OR＝6．161）和新辅助放化疗（OR＝19．045）是腹腔镜直肠癌保肛手术后发生吻合口瘘的独立危险因子。经采取充分引流、静脉使用生长抑素、双套管冲洗及回肠或横结肠造口等方法进行处理后,吻合口瘘均痊愈。结论体质量指数、吻合口距齿状线距离、手术方式和新辅助放化疗等是腹腔镜直肠癌保肛手术后发生吻合口瘘的独立危险因子。对伴有独立危险因子病例采取预防性造口,可以降低非计划二次手术的概率,减轻瘘的程度,缩短瘘的愈合时间。围手术期采取适当措施,可有效降低吻合口瘘的发生率。     

食管癌贲门癌切除及食管(管状胃)胃侧侧吻合术

目的探讨食管癌、贲门癌切除、食管(管状胃)胃侧侧吻合术的治疗效果及应用前景。方法共有32例患者行此手术。贲门癌6例、食管癌26例;其中胸下段9例,胸中段12例,胸上段5例。术中按肿瘤手术切除原则常规游离食管及近端胃,切除肿瘤。行主动脉弓下吻合9例,经食管床主动脉弓上吻合10例,左胸左颈两切口4例,右胸顶吻合3例,右胸颈腹三切口6例。22例患者应用管状胃代食管,10例患者应用全胃代食管。行食管胃端端吻合+侧侧吻合术15例;食管胃端侧吻合+侧侧吻合术10例;胸下段食管癌患者行食管管状胃全侧侧吻合术7例。结果本组病例术后分期分别为Ⅱa期9例,Ⅱb期11例,Ⅲ期12例。全部病例手术顺利,术后未出现吻合口瘘,术后2周复查上消化道钡透及胃镜检查均见吻合口通畅、无狭窄,术后随诊0.5～2年不等,均未见吻合口狭窄。结论食管癌、贲门癌切除食管(管状胃)胃侧侧吻合术可降低吻合口并发症尤其是狭窄的发生,值得临床推广。     

食管癌术后颈部吻合口纵隔、胸腔内瘘的诊治--附5例报告及文献复习

背景与目的:食管癌术后胃食管颈部吻合口内瘘入纵隔、胸腔时形成特殊类型的吻合口瘘,诊治均较困难,处理不当则易危及生命。本研究旨在探讨此类吻合口瘘的发生原因、预防措施、诊断方法、正确的治疗手段。方法:回顾性分析本院诊治的5例食管癌术后颈部吻合口纵隔、胸腔内瘘患者的临床资料并对相关文献进行复习。结果:本组三切口食管癌手术的颈部吻合口内瘘的发生率为1.83%(4/219)。5例患者内瘘发生时间为术后第1～13天,其中2例合并支气管胸膜瘘。形成颈部吻合口纵隔、胸腔内瘘的原因主要包括吻合口张力过大,吻合位置过低,食管胸廓出口未满意封闭固定,吻合技术缺陷,头颈部摆动幅度过大等。当出现术后突发的高热、呼吸困难、胸痛,合并颈部吻合口外漏,经敞开后病情无好转,X线见纵隔影增宽,液气胸,经口服美蓝,食管造影和CT检查发现吻合口内瘘入纵隔或胸腔即可确诊。通过及时诊断、充分引流和内外冲冼、足够的营养支持、合理的抗生素应用和对合并支气管胸膜瘘者采用脓胸廓清及带蒂肌瓣填塞手术,患者均在较短期内得以治愈。结论:食管癌术后胃食管颈部吻合口内瘘多发生在术后1～13天,病情多较危重,及时发现并妥善处理包括积极手术介入可明显缩短病程,显著降低吻合口内瘘死亡率。     

Complications of colonic interposition

The roentgenographic and surgical experience with 44 patients treated with colon interpositions was examined. Forty-two of these patients had carcinoma of the esophagus. Staged therapy consisted of mediastinal irradiation, colonic interposition, and total esophagectomy. The more common complications related to luminal patency and conduit integrity. A total of 29.5% developed anastomotic narrowing due to postoperative edema. Anastomotic leaks arose only at the proximal anastomosis and had an incidence rate of 31.8%. Thirty-four percent had fistulous tracts originating in the reconstructed upper gastrointestinal tract. In eighty percent of the patients with leaks or fistulae, their defects healed spontaneously or with simple drainage. Strictures were encountered in 59.1%, and there were 5 instances of colonic graft ischemia. The mortality directly related to surgery was 6.8%. Ischemia, particularly at the cervical anastomosis, is probably the most common cause of complications. Radiographic evaluation is recommended using a single contrast barium examination unless gross extravasation is expected.     

食管癌、贲门癌手术后并发症治疗体会（附106例）

目的：探讨食管癌、贲门癌切除术后并发症的防治。方法：1984年5月至2008年5月手术治疗825例食管癌、贲门癌,回顾分析发生各类并发症共106例的临床资料。结果：106例中吻合口瘘24例;急性呼吸衰竭20例;乳糜胸6例;脓胸32例;心血管系统并发症18例;膈疝6例;治愈94例,死亡12例。结论：食管癌、贲门癌切除术创伤大,术后并发症及死亡率较高,其中以吻合口瘘及循环、呼吸系统并发症多而严重。     

直肠低位前切除术后吻合口瘘的处理与预防（附24例报告）

目的：探讨直肠低位前切除术后吻合口瘘的治疗措施及术中处理细节.方法：对我院2008年1月至2012年12月期间直肠低位前切除术后出现吻合口瘘患者的临床资料进行回顾分析.结果：510例行直肠低位前切除术的患者中,24例术后出现吻合口瘘,吻合口瘘发生率4.7%;吻合口瘘发生于术后4天～25天（中位8天）;该24例患者中,8例（33.3%）行肠造瘘手术,16例（66.7%）行局部置管冲洗引流,配合全身营养支持治愈;无患者死亡.结论：大多数吻合口瘘都可以通过保守治疗痊愈,术中精细操作,确保肠段的血供和无张力吻合是预防直肠低位前切除术后吻合口瘘的关键.